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The early identification of patients with small bowel obstruction who require surgical treatment could potentially lead to improved patient outcomes. We evaluated the efficacy of point-of-care procalcitonin for predicting surgical treatment among patients with small bowel obstruction.This was a prospective observational study. We measured serum procalcitonin levels in patients who presented to the emergency department and were diagnosed with small bowel obstruction from April 1, 2018 through March 31, 2019. Patients were grouped into two groups: the elevated procalcitonin and normal procalcitonin groups. Our primary outcome was surgical treatment.A total of 53 patients with small bowel obstruction were included in the study, and 11 patients (20.8%) were treated operatively. Baseline characteristics were similar, except for age, between the elevated procalcitonin (≥0.12 ng/ml) and normal procalcitonin groups. The elevated procalcitonin level was significantly correlated with surgical treatment and hospital length of stay (p 0.05). The sensitivity, specificity, and positive likelihood of procalcitonin for the former were 45.5%, 85.7%, and 5.0 respectively.The patients with small bowel obstruction who had elevated procalcitonin levels on presentation showed significantly higher rate of surgical treatment than those who had normal procalcitonin levels. Point-of-care procalcitonin might predict the need for surgical treatment in patients with small bowel obstruction and could be used as an additional diagnostic test. Further studies with more patients are needed to investigate the predictive value of point-of-care procalcitonin for surgical treatment.

Introduction Massive hemorrhage is often associated with unstable pelvic fractures with posterior ring injury. Initial pelvic radiography alone may not detect these posterior lesions. We examined whether the presence of an anterior pelvic fracture on initial pelvic radiography alone may identify patients who are at a high risk of major hemorrhage. Materials and methods A total of 288 patients with pelvic fractures were admitted to the Fukui Prefectural Hospital during an 11-year period. After excluding 33 patients who were in cardiopulmonary arrest on arrival and nine with concomitant abdominal organ injuries requiring emergency laparotomy, 246 eligible patients were retrospectively reviewed. Anterior pelvic fractures were defined as displacement of the obturator ring, obturator ring with laterality, or displacement of the pubic symphysis on pelvic radiography. Results Massive hemorrhage was identified in 106 of 246 patients. Patients with massive hemorrhage had a higher frequency of anterior pelvic fractures on pelvic radiography and higher frequency of posterior pelvic fractures on computed tomography than those without massive hemorrhage. Logistic regression analysis identified displacement of the obturator ring by ≥5 mm, obturator ring with laterality of ≥5 mm, and displacement of the pubic symphysis by ≥4 mm on pelvic radiography as predictors of massive pelvic hemorrhage. Conclusion The results of the present study suggested that the presence of displaced anterior lesions of the pelvic ring on pelvic radiography alone, without the use of computed tomography during the initial treatment stage, may promptly identify patients at high risk of massive pelvic hemorrhage who require intervention for hemorrhage control.

Aim Tracheostomy is a common procedure for intubated patients with traumatic brain injury (TBI) in the intensive care unit (ICU) but optimal timing and the predictors of tracheostomy are still unclear. The aim of our study was to explore whether the traumatic variables of head injury predict the need for tracheostomy in intubated TBI patients. Methods A single‐center, retrospective observational study including a series of TBI patients admitted to Fukui Prefectural Hospital from April 1, 2004 to March 31, 2020 was carried out. Our primary outcome was tracheostomy. Patients with TBI who were intubated and admitted into the ICU within 24 h after injury were enrolled. Exclusion criteria were age less than 18 years, pregnancy, mortality within 24 h, post‐cardiac arrest syndrome, and patients for whom life‐sustaining interventions were withheld. Radiologic images were also reviewed and the morphology of the head injury was categorized. Results Seventy‐six patients were included. Forty‐six patients (60.5%) underwent tracheostomy and 30 patients (39.5%) were successfully extubated. Calvarial fracture (odds ratio [OR] 0.34; 95% confidence interval [CI], 0.13–0.88; P = 0.03), Injury Severity Score (OR 1.07; 95% CI, 1.00–1.15; P = 0.04), and Glasgow Comas Scale score (OR 0.84; 95% CI, 0.73–0.96) were statistically significant in the univariable analysis. Multivariate logistic regression identified calvarial fracture as an independent predictor for tracheostomy. The model involving calvarial fracture, Injury Severity Score ≥16, and Glasgow Coma Scale score ≤8 showed the area under the receiver operating characteristic curve for the model was 0.737 (95% CI, 0.629–0.846). Conclusions The absence of calvarial fracture could predict the necessity for tracheostomy in intubated TBI patients when combined with other factors. Further prospective randomized trials are necessary to confirm the findings., Calvarial fracture (odds ratio [OR] 0.34; 95% confidence interval [CI], 0.13–0.88; P = 0.03), Injury Severity Score (ISS) (OR 1.07; 95% CI, 1.00–1.15; P = 0.04), and Glasgow Coma Scale score (GCS) (OR 0.84; 95% CI, 0.73–0.96) were statistically significant in the univariable analysis. Multivariate logistic regression identified calvarial fracture as an independent predictor for tracheostomy and the area under the receiver operating characteristic curve for the model involving calvarial fracture, ISS ≥16, and GCS ≤8 was 0.737 (95% CI, 0.629–0.846). The absence of calvarial fracture could predict the necessity for tracheostomy in intubated patients with traumatic brain injury, when combined with other factors.

Background The optimal tube size for an emergent thoracostomy for traumatic pneumothorax or hemothorax is unknown. Both small catheter tube thoracostomy and large-bore chest tube thoracostomy have been shown to work for the nonemergent management of patients with traumatic pneumothorax or hemothorax. This study was conducted to compare the efficacy of a small chest tube with that of a large tube in emergent thoracostomy due to chest trauma. Our hypothesis was that there would be no difference in clinical outcomes including tube-related complications, the need for additional tube placement, and thoracotomy, with the replacement of large tubes with small tubes. Methods A retrospective review of all patients with chest trauma requiring tube thoracostomy within the first 2 h from arrival at our emergency department over a 7-year period was conducted. Charts were reviewed for demographic data and outcomes including complications and initial drainage output. Small chest tubes (20–22 Fr) were compared with a large tube (28 Fr). Our primary outcome was tube-related complications. Secondary outcomes included additional invasive procedures, such as additional tube insertion and thoracotomy. Results There were 124 tube thoracostomies (small: 68, large: 56) performed in 116 patients. There were no significant differences between the small- and large-tube groups with regard to age, gender, injury mechanism, systolic blood pressure, heart rate, and injury severity score. Both groups were similar in the posterior direction of tube insertion, initial drainage output, and the duration of tube insertion. There was no significant difference in the primary outcomes of tube-related complications, including empyema (small: 1/68 vs. large: 1/56; p = 1.000) or retained hemothorax (small: 2/68 vs. large: 2/56; p = 1.000). Secondary outcomes, including the need for additional tube placement (small: 2/68 vs. large: 4/56; p = 0.408) or thoracotomy (small: 2/68 vs. large: 1/56; p = 1.000), were also similar. Conclusion For patients with chest trauma, emergent insertion of 20–22 Fr chest tubes has no difference in the efficacy of drainage, rate of complications, and need for additional invasive procedures compared with a large tube (28 Fr).

IntroductionRecent advances in troponin sensitivity enabled early and accurate judgement of ruling-out myocardial infarction, especially non-ST elevation myocardial infarction (NSTEMI) in emergency departments (EDs) with development of various prediction-rules and high-sensitive-troponin-based strategies (hs-troponin). Reliance on clinical impression, however, is still common, and it remains unknown which of these strategies is superior. Therefore, our objective in this prospective cohort study is to comprehensively validate the diagnostic accuracy of clinical impression-based strategies, prediction-rules and hs-troponin-based strategies for ruling-out NSTEMIs.Methods and analysisIn total, 1500 consecutive adult patients with symptoms suggestive of acute coronary syndrome will be prospectively recruited from five EDs in two tertiary-level, two secondary-level community hospitals and one university hospital in Japan. The study has begun in July 2018, and recruitment period will be about 1 year. A board-certified emergency physician will complete standardised case report forms, and independently perform a clinical impression-based risk estimation of NSTEMI. Index strategies to be compared will include the clinical impression-based strategy; prediction rules and hs-troponin-based strategies for the following types of troponin (Roche Elecsys hs-troponin T; Abbott ARCHITECT hs-troponin I; Siemens ADVIA Centaur hs-troponin I; Siemens ADVIA Centaur sensitive-troponin I). The reference standard will be the composite of type 1 MI and cardiac death within 30 days after admission to the ED. Outcome measures will be negative predictive value, sensitivity and effectiveness, defined as the proportion of patients categorised as low risk for NSTEMI. We will also evaluate inter-rater reliability of the clinical impression-based risk estimation.Ethics and disseminationThe study is approved by the Ethics Committees of the Kyoto University Graduate School and Faculty of Medicine and of the five hospitals where we will recruit patients. We will disseminate the study results through conference presentations and peer-reviewed journals.

Objective The efficacy of nonoperative management of blunt thoracic aortic injury (BTAI) was evaluated in patients with pseudoaneurysm. Methods A retrospective review was done for patients with BTAI at Fukui Prefectural Hospital during a 9-year period. Charts were reviewed for age, gender, Injury Severity Score, Abbreviated Injury Scale for each body area, initial type of aortic injury, site of aortic injury, type of definitive management, complications, and outcomes. Results Eighteen patients with BTAI were treated at Fukui Prefectural Hospital. Of 18 patients with pseudoaneurysm, seven patients were hemodynamically unstable and four patients died because of associated injuries; there were no aortic-related deaths. All 14 surviving patients were followed up for an average of 40.9 months. Only two patients with pseudoaneurysm required operative management because of the progression of the pseudoaneurysm. The pseudoaneurysm/normal aortic diameter ratio of those with any intervention was higher than that of those with nonoperative management. Conclusions BTAI with pseudoaneurysm can be managed nonoperatively, with about 10% risk of progression to require surgical repair.